2753 Got the GIST: Multidisciplinary Management of an Acute Bleeding Gastrointestinal Stromal Tumor

Abstract

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) account for 1%-3% of all gastrointestinal tumors. They most commonly arise in the stomach followed by the jejunum/ileum. Presentation varies from incidental discovery during autopsy or endoscopy to acute gastrointestinal (GI) bleeding or bowel obstruction. We report a case of this rare neoplasm in a patient with an acute GI bleed, treated endoscopically with hemostatic spray and ultimately with arterial embolization and surgical resection. CASE DESCRIPTION/METHODS: A 67-year-old female with a family history of colorectal cancer presented to the emergency department for hematemesis and left lower quadrant abdominal pain for 1 day. Physical examination was notable for left lower quadrant tenderness to palpation. Initial laboratory data showed a hemoglobin of 12.8 g/dL from 14.4 g/dL 8 months prior. A CT scan of the abdomen demonstrated a 3.2 × 4.1 cm well-circumscribed mass along the lesser curvature of the stomach arising from the gastric wall. Overnight, she had an episode of large volume hematemesis and became tachycardic and hypotensive. Her hemoglobin dropped to 7 g/dL. An esophagogastroduodenoscopy (EGD) showed LA Grade D esophagitis and a submucosal ulcerated gastric tumor on the lesser curvature of the stomach to which Hemostatic powder spray was applied. She initially refused surgical intervention and remained hemodynamically stable for ∼12 hours after EGD. She then had multiple episodes of hematemesis with hypotension despite blood transfusions. She underwent embolization to the left gastric artery after which hemostasis was achieved. She then decided to proceed with surgical resection of the gastric mass. Pathology confirmed the diagnosis of GIST, spindle-cell type with strongly positive stains for DOG-1 and CD117. DISCUSSION: GISTs are rare tumors that originate from mesenchymal stem cells. Although 40% of gastric GISTs present with GI bleeding, there are no clear guidelines on the management of these lesions. Therapeutic endoscopy and arterial embolization are effective methods used in the management of GISTs with acute bleeding. Hemostatic spray, an inorganic powder that concentrates clotting factors on bleeding surfaces, can be used adjunctively to other methods for the management of bleeding GISTs especially when traditional endoscopic techniques are challenging or when surgery is not an option. This case highlights the importance of a multidisciplinary approach in the management of these rare tumors.